William J Meurer1,2,3, Patricia Johnson2, Devin Brown2,3, Alexander Tsodikov4, Brigid Rowell2, Angela Fagerlin5,6, Steven A Telian7, Laura Damschroder8, Lawrence C An9,10, Lewis B Morgenstern1,2,3, Kevin A Kerber2,3. 1. Department of Emergency Medicine. 2. Department of Neurology. 3. Stroke Program. 4. Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan. 5. Department of Population Health Sciences, University of Utah. 6. Salt Lake City VA Center for Informatics Decision Enhancement and Surveillance (IDEAS), Salt Lake City, Utah. 7. Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan. 8. Implementation Pathways, LLC. 9. Department of Internal Medicine. 10. Center for Health Communication and Research, University of Michigan, Ann Arbor, Michigan.
Abstract
IMPORTANCE: Benign paroxysmal positional vertigo (BPPV) is a common cause of acute dizziness. Strong evidence exists for diagnosing BPPV using the Dix-Hallpike Test (DHT) and treating it with the canalith repositioning maneuver (CRM). Despite this, both are infrequently used in the emergency department (ED). OBJECTIVE: As an early method to evaluate a BPPV-focused educational intervention, we evaluated whether an educational intervention improved ED provider performance on hypothetical stroke and BPPV cases delivered by vignette. DESIGN: A randomized, controlled, educational intervention study in ED physicians. The intervention aimed to promote the appropriate use of the DHT and CRM. A BPPV vignette, a stroke-dizziness (safety) vignette, and vignette scoring schemes (higher scores indicating more optimal care) used previously established vignette methodology. SETTING: We recruited participants at the exhibitor hall of an emergency medicine annual meeting. PARTICIPANTS: We recruited 48 emergency physicians. All were board certified or residency trained and board eligible. All were engaged in the active practice of emergency medicine. None were trainees. INTERVENTIONS: Intervention group: a narrated, educational presentation by computer followed by the clinical vignettes. CONTROL GROUP: Received no educational intervention and completed the clinical vignettes-intended to mirror current clinician practice. MAIN OUTCOME MEASURE: Primary endpoint: total score (out of 200 points) on a vignette-based scoring instrument assessing the performance of history, physical, and diagnostic testing on hypothetical stroke and BPPV cases. RESULTS: The efficacy threshold was crossed at the interim analysis. The intervention group had higher performance scores compared with controls (113.2 versus 68.6, p < 0.00001). BPPV and safety subscores were both significantly higher in the intervention group. Sixty-two percent of the intervention group planned to use the DHT versus 29% of controls. After the vignette described characteristic BPPV nystagmus, 100% of the intervention group planned to use the CRM versus 17% of controls. CONCLUSIONS AND RELEVANCE: The educational intervention increased provider performance in dizziness vignettes, including more frequent appropriate use of the DHT/CRM. These findings indicate the intervention positively influenced planned behavior. Future work is needed to implement and evaluate this intervention in clinical practice.
RCT Entities:
IMPORTANCE: Benign paroxysmal positional vertigo (BPPV) is a common cause of acute dizziness. Strong evidence exists for diagnosing BPPV using the Dix-Hallpike Test (DHT) and treating it with the canalith repositioning maneuver (CRM). Despite this, both are infrequently used in the emergency department (ED). OBJECTIVE: As an early method to evaluate a BPPV-focused educational intervention, we evaluated whether an educational intervention improved ED provider performance on hypothetical stroke and BPPV cases delivered by vignette. DESIGN: A randomized, controlled, educational intervention study in ED physicians. The intervention aimed to promote the appropriate use of the DHT and CRM. A BPPV vignette, a stroke-dizziness (safety) vignette, and vignette scoring schemes (higher scores indicating more optimal care) used previously established vignette methodology. SETTING: We recruited participants at the exhibitor hall of an emergency medicine annual meeting. PARTICIPANTS: We recruited 48 emergency physicians. All were board certified or residency trained and board eligible. All were engaged in the active practice of emergency medicine. None were trainees. INTERVENTIONS: Intervention group: a narrated, educational presentation by computer followed by the clinical vignettes. CONTROL GROUP: Received no educational intervention and completed the clinical vignettes-intended to mirror current clinician practice. MAIN OUTCOME MEASURE: Primary endpoint: total score (out of 200 points) on a vignette-based scoring instrument assessing the performance of history, physical, and diagnostic testing on hypothetical stroke and BPPV cases. RESULTS: The efficacy threshold was crossed at the interim analysis. The intervention group had higher performance scores compared with controls (113.2 versus 68.6, p < 0.00001). BPPV and safety subscores were both significantly higher in the intervention group. Sixty-two percent of the intervention group planned to use the DHT versus 29% of controls. After the vignette described characteristic BPPV nystagmus, 100% of the intervention group planned to use the CRM versus 17% of controls. CONCLUSIONS AND RELEVANCE: The educational intervention increased provider performance in dizziness vignettes, including more frequent appropriate use of the DHT/CRM. These findings indicate the intervention positively influenced planned behavior. Future work is needed to implement and evaluate this intervention in clinical practice.
Authors: Kevin A Kerber; Lewis B Morgenstern; William J Meurer; Thomas McLaughlin; Pamela A Hall; Jane Forman; A Mark Fendrick; David E Newman-Toker Journal: Acad Emerg Med Date: 2011-06 Impact factor: 3.451
Authors: Kevin A Kerber; William J Meurer; Devin L Brown; James F Burke; Timothy P Hofer; Alexander Tsodikov; Ellen G Hoeffner; A M Fendrick; Eric E Adelman; Lewis B Morgenstern Journal: Neurology Date: 2015-10-28 Impact factor: 9.910
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Authors: Kevin A Kerber; Jane Forman; Laura Damschroder; Steven A Telian; Angela Fagerlin; Patricia Johnson; Devin L Brown; Lawrence C An; Lewis B Morgenstern; William J Meurer Journal: Neurol Clin Pract Date: 2017-06
Authors: M von Brevern; A Radtke; F Lezius; M Feldmann; T Ziese; T Lempert; H Neuhauser Journal: J Neurol Neurosurg Psychiatry Date: 2006-11-29 Impact factor: 10.154
Authors: Kevin A Kerber; Laura Damschroder; Thomas McLaughlin; Devin L Brown; James F Burke; Steven A Telian; Alexander Tsodikov; Angela Fagerlin; Lawrence C An; Lewis B Morgenstern; Jane Forman; Sandeep Vijan; Brigid Rowell; William J Meurer Journal: Ann Emerg Med Date: 2019-12-20 Impact factor: 5.721
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